Weaving the DNA of #Healthcare. Learn about front-line clinical informatics, clinical workflow design, and EMR implementation with an experienced CMIO. Open discussion is encouraged, education is a priority. All opinions are strictly my own.

Wednesday, February 22, 2012

So I'm at the HIMSS12 conference in Las Vegas this week, where it's been very inspiring - Meeting lots of #HealthIT and #Informatics people with whom I share a lot of the same passions and thoughts. Breakfast started with Eric Dishman (@ericdishman) of Intel talking about "Big Data", the greying of the world population driving the need for technology solutions to healthcare and importance of disruptive innovation. Biz Stone (@biz) of Twitter opened up the keynote today, talking about opening up information flows and the modern information revolution. The common theme at this conference seems to be : A need for disruptive innovation to help drive development of a more efficient, more personalized, and more distributed healthcare model.

For example, yesterday at the #CMIO forum, after listening to all of us share stories, it became clear that two of the important roles of a #CMIO are to be a thought leader and to be a cautious steward of disruptive innovation that really helps patients.

Of course, since I'm passionate about creating #Informatics platforms and well-designed tools that clinicians and administrators can use to work together, I thought : Could I look a step higher, and develop something that helps more than just the clinicians? Could we make something that helps healthcare efficiency on a national level?

And so for inspiration, I turned to a common theme in engineering and development : The three worlds of development.

A. THE THREE WORLDS

Engineers and software engineers are very familiar with this concept - Clinicians, administrators, and politicians generally aren't.

One of the fundamental tenets of good Informatics is understanding the way ideas come to fruition in a safe and organized way - By moving an idea through three different stages of organized development :

The DEVELOPMENT stage

The TESTING stage

The LIVE (sometimes called "PRODUCTION") stage

Huh? What does this mean, exactly?

To help develop things in a safe, controlled, and predictable way, most engineers think long and hard about:

How can I DEVELOP an idea safely?

How can I TEST an idea safely?

How can I make something go LIVE safely?

And so, most engineers and informaticists are familiar with these three different worlds and how to use them :

"DEV" - (the "development" world) - Typically, used by people who help build/develop the idea

"TEST" - (the "testing" world) - Typically used by those end-users who test the idea

"PROD" - (the "live" world) - Typically used in real-life by those people who actually use the idea

So if you train your brain to think about these different stages of organized, controlled development, you will actually be better at developing things in an organized and predictable way.

The funny thing is that often these three worlds are used by engineers and Informaticists, but the rules actually apply to many, many other things we develop in real life, whether we realize it or not. For example, many people live in a house :

"DEVELOPMENT PHASE" of House : Point where builder is building the house according to specifications

"TESTING PHASE" of House : Point where safety inspector looks at house design and tests for adequate safety

"PRODUCTION/LIVE PHASE" of House : Point where person moves into house

Or you might send an email :

"DEVELOPMENT PHASE" - Point where you are writing and drafting the email

"TESTING PHASE" - Point where you are proof-reading the email and checking the spelling

"PRODUCTION/LIVE PHASE" - Point where you click "SEND" and make the email a reality

Or you might send a paper letter to someone :

"DEVELOPMENT PHASE" - Point where you are writing and drafting the mail

"TESTING PHASE" - Point where you proof-read the letter before putting it in the envelope

"PRODUCTION/LIVE PHASE" - Point where you drop the letter in the mail to make it a reality

So I usually recommend to new Informaticists that they should become familiar with these three worlds, and :

Who uses which world for what?

What process will you use to transfer ideas from one world to the other?

It's also why I personally feel that some older healthcare change concepts like 'Test of Change' are kind of outdated - They only encourage crossing over from one world to the other without a formal process.

Again, a good Informaticist understands these three worlds, how to use them, and helps an organization define the standards by which tools will be moved through these three stages of development. Generally, with regards to Health IT development :

Software engineers/analysts live in the "DEV" world (often with help of an Informaticist)

Owners/End Users live in the "TEST" world (often with the help of an Informaticist), and

Real-life people live in the "LIVE" world.

B. THE CONCEPT : SimHospital

So to help HIMSS and the ONC drive some really innovative thinking about bending the healthcare cost curve, I wondered - Could we actually use these common engineering/informatics principles to help more than just software engineers and informaticists? In other words, could we use these principles to help patients, administrators, clinicians, and politicians understand healthcare better?How would we do that?

So it dawned upon me, a great tool that could help improve healthcare management and delivery would be a robust TESTING GROUND for healthcare change. Enter the idea : SimHospital.

SimHospital would be a computer-modeled, virtual hospital where all of the basic characters in healthcare could live in a safe, virtual environment that allows for testing. Just like the popular SecondLife world or TheSims series, it would be a virtual hospital with virtual-reality avatars that are built to behave much like their real-life counterparts - E.g. virtual patients, doctors, nurses, pharmacists, respiratory therapists, couriers, and other hospital staff could all be designed to behave in fairly predictable manner, based on certain variables like :

Education/training

Allowed tasks

Predicted compliance with tasks

Clinical tools and communication to facilitate interactions between team members

Contracts and Policies to guide behaviors

And I think in this virtual, simulated world, we could allow better testing of ideas like :

How will changing a policy or regulation impact care?

How will changing a clinical or administrative tool impact care?

How will changing a workflow impact resources?

How will adding/removing a department impact workflows?

This virtual world would also be an amazing training tool for clinicians, administrators, and politicians - If we commonly ask pilots to train hours in a flight simulator, maybe this SimHospital could be used to train healthcare leaders to understand their environments better.

It could also, if developed, be used as a tool to help do predictive modeling for healthcare outcomes - If the ACO movement is going to make organizations responsible for both the delivery and outcomes of healthcare, then SimHospital could be a very useful tool to predict the outcomes of a particular intervention.

And if we wanted to expand beyond the boundaries of the hospital, we could also develop SimHealthcareto model the hospital and outside PCPs and specialists, again, to help predict how a change in one or more variables will probably lead to what results.

I think it could be a pleasantly disruptive way of improving education for healthcare leaders and simultaneously help with the predictive modeling that will be required for ACOs to succeed.

As with many of my posts, I'd like to throw the idea out there, and would be interested in hearing comments. (Do I have any readership from SecondLifeor TheSims programmers who want to use their skills to help reform healthcare?) :)

Remember : This blog is for education/discussion and brainstorming only. Your mileage may vary. Always interested in hearing your thoughts and comments!

Sunday, February 5, 2012

As I've mentioned in previous posts, the American government cannot set up a national patient identifier. So projects like NHIN Direct generally rely on a document push mechanism which, essentially, allows one healthcare provider to push an authorized, HIPAA-secure document to another healthcare provider.

I'll admit it - I wish we could have pull.

The reason I want pull? A centralized, patient-centric medical record (like in the #SpeakFlower model) would make it much easier for various providers to pull and update information in a virtually central location. Pushing documents is going to have its workflow challenges, and leave some with the question, "Where is the patient's real chart?".

So since I recently became involved in our Massachusetts discussion on Health Information Exchange, I'm struggling with the question of how to implement a state-wide HIE system that will allow providers, at least initially, to push documents to eachother.

So my first informatics question, on being given this challenge, is : What will people push? Who will push it? And to whom? And when?

Could we develop any group standard templates for standardized documentation, to save us all development costs?

Could we develop any rudimentary, area-wide clinical governance so we can share documentation easier, and thus all benefit from a common language?

Ultimately, who will push what documentation to whom, and when?

And after a rousing discussion, the answer I heard was this : Everyone has a different opinion.

I guess it's entirely understandable... ICU docs, PCPs, surgeons, specialists, hospitalists, and everyone else has a common goal - making the patient healthier - but they have different training and thus they all have different needs. This is why when I hear docs say "I just need the important information!", I smile because ultimately, all of the information in a chart is important - It just depends on your context and clinical needs.

So I'm left with the ultimate Informatics challenge - How can we get the right information to the right person in the right place in the right time in the right way? Especially when everyone has a different opinion on what the right information is?

And is there any way we can develop a standard lingua franca that all doctors speak?

Is there something that all docs would know how/when to use, in a standard way?

THE CHALLENGE

So to better understand the challenge here, I looked to the most common issues I hear doctors, nurses, and administrators talking about :

Med Reconciliation (at virtually every stage of care)

Handoffs inside a hospital

PCPs wanting notification that their patient has been admitted

PCPs wanting discharge summaries when their patients are discharged

Quality

Waiting times

And given the push mechanism it looks like we are going to get, at least initially, how are we going to set any standards?

There is one thing issues #1-6 above share : They are mostly all caused by the lack of a common, portable, #SpeakFlower-type, patient-centered chart, which we currently lack in modern private healthcare. (Note : I say private healthcare because the Veteran's Administration/VA VistA system actually has a pretty seamless, continuous, portable patient chart that only works inside the VA system for various political and cultural reasons...)

But in a private, push world, is there any way we could we start to approach some kind of a portable, patient-centered chart?

In other words, is there any way we could leverage our push system in a way that actually simulates a patient-centered chart?

And how would we implement this?

THE CURRENT STATE

Looking at the current buffet table of documentation, it's no wonder that every doctor has a differrent opinion of what they need. There aren't really any hard standards for clinical documentation. As I've mentioned in previous posts, most doctors learn about documentation from things like the Washington Manual Internship Survival Guide. So as a result, most physicians are familiar with things like :

Admission H&P

Progress Note

Discharge Summary

Transfer Note

Encounter Note

Procedure Note

Visit Note

Consult Note

And so when our Interstate 91 Informatics group got together, it's no wonder every doctor had a different opinion of which note they would want to get, and when.

So to look for inspiration on how to build a standardized document that every doctor would know how to use, and when to push to whom, again I thought : Could we make a standardized push document that approaches the portable, patient-centered chart we all want?

THE INSPIRATION

It dawned upon me that to solve this problem, we will need a new type of note. And so if it's something that's not in the Washington Manual Internship Survival Guide, it would have to be something that was so useful, so intuitive, and so desirable - like McDonalds French Fries - that every doctor would *want* to use this note, update it, and push it to the right person at the right time.

So then I thought - We are really asking for a portable, mini-chart that we can push around to the next provider.

And then I wondered, "What will we name it?" The "Mini-chart"? The "Patient Summary"?

What we're really talking about here is a "Patient Handoff Note" - The 'mini-chart' - And to make it extra-intuitive, I've decided to nickname it "The Football".

(Interestingly - "The Football" is also the nickname given to the "Nuclear Football" which the President of the United States carries around at all times, which according to Wikipedia is designed to be "a mobile hub in the strategic defense system of the United States" - A portable, role-centric tool for making important decisions... Huh! Talk about portable documentation!)

Also by nicknaming it "The Football", it gives users a visual clue about how to use it and when to punt it to the next physician.

THE PATIENT HANDOFF NOTE ("FOOTBALL")

The Patient Handoff Note ("Football") is basically a patient mini-chart, designed to be used in handing off care from one physician to another. In other words, physicians could think of the Patient Handoff Note ("Football") as a document that they update and push to the next physicianexpected to see the patient.

Who is the next physician expected to see the patient? Whoever is expected to see or cover the patient next. If you're a PCPexpecting a specialist to see your patient, you'll update the football and send it to the specialist. If you're a specialist done with the consult, expecting the PCP to see the patient next, you'll update the football and send it back with the patient to the PCP.

Of course, the key word here is expected - What if a patient has an unexpected trip to the ED?

I thought the note should be of such high value that, on arrival, the ED physicians would request the Football from the PCP. (By doing this, they would ensure the PCP knew about the visit.) And when the ED doc decides to admit the patient to the Hospitalist, they would update the football and push the patient and football to the expected Hospitalist.

And the admitting hospitalist could update and push the football to the expected hospitalist the next day.

And the daytime hospitalist could update the football and push it to the expected overnight covering staff.

And the overnight covering staff, if needed, could update the football and push it to the daytime hospitalist.

And the daytime hospitalist, on discharging the patient, could update the football and push the patient and football back to the PCP.

It could virtually replace notes involved in the expected transfer of care such as the transfer note, overnight coverage signout, discharge note, and consult referral

Nicknaming it "The Football" makes it fairly intuitive about its importance and who to push it to and when

In a push environment, in an unexpected transfer of care, an ED doc or Hospitalist requesting this from the PCP would pretty much ensure the PCP was notified about the admission in a timely basis.

It's definitely an off-of-the-beaten-path idea, but I'm going to suggest it to my fellow physicians here in Massachusetts, as we start to warm up our state-wide HIE and get it running. Will let you know the results!

Is this note wishful thinking, or just crazy? Always interested in feedback and questions! Send me your thoughts and ideas! Love the discussion just for education's sake!